Shoulder Dystocia nursing care: what to assess and what to do first

Recognising it at the bedside

The fetal head delivers, then retracts back against the perineum instead of restituting normally. This is the turtle sign, and it is the single most reliable bedside cue that the anterior shoulder has caught on the maternal symphysis pubis. Once you see it, treat the birth as an obstetric emergency, not a slow delivery.

Time matters from this point. Call for help immediately: the delivering clinician needs extra hands, and most units activate a dystocia team that includes anaesthesia and neonatal staff. Note the time the head delivered, since the interval to shoulder delivery is documented and guides neonatal assessment afterward. Do not wait to see if the next contraction resolves it on its own.

Why the classic presentation misleads

Shoulder dystocia is often taught as predictable from risk factors: fetal macrosomia, maternal diabetes, a prolonged second stage, or a history of dystocia. In practice, most cases occur in labours with no identified risk factor, and estimated fetal weight by ultrasound or Leopold's manoeuvres is a poor predictor. Do not let a low-risk labour lower your vigilance during the second stage.

The other misleading feature is that dystocia looks, for a moment, like a normal delivery that has simply paused. Staff who have not seen it before may assume the mother needs to push harder or that the head is just slow to restitute. The turtle sign and the maternal team's inability to deliver the shoulder with gentle downward traction are what separate this from a normal pause, and they call for an immediate change in technique, not more of the same effort.

Priority nursing actions

The two manoeuvres with the best evidence are McRoberts position and suprapubic pressure, and they are used together, not sequentially. For McRoberts, sharply flex the mother's hips onto her abdomen, which flattens the lumbosacral lordosis and rotates the symphysis pubis cephalad, freeing the impacted shoulder in a large proportion of cases. A nurse on each leg can perform this quickly once called.

Suprapubic pressure is applied by a second person directly above the symphysis pubis, pushing at an angle to adduct the anterior shoulder and dislodge it from behind the pubic bone. It is not the same as fundal pressure, and fundal pressure must never be used here: pressure on the fundus pushes the shoulder further into the pelvis and increases the risk of uterine rupture and worsened impaction. If asked to apply pressure during a dystocia, confirm suprapubic, not fundal, before you act.

Beyond positioning, your role includes clear communication of elapsed time, preparing for possible episiotomy, and readying the neonatal resuscitation area, since these infants may need immediate support.

Labs and diagnostics to expect

Shoulder dystocia is a clinical diagnosis made at the moment of delivery, so there is no antenatal test that confirms it. Postpartum, the focus shifts to assessing for the complications it causes. Send a full blood count and coagulation studies if postpartum haemorrhage is suspected, since brachial plexus manoeuvres and additional manipulation increase the risk of uterine atony and lacerations.

For the neonate, cord blood gases are drawn immediately, since a prolonged head-to-body interval can cause hypoxia. The neonatal team will also examine for clavicular fracture and brachial plexus injury before the infant leaves the delivery room, and these findings should be documented alongside the exact manoeuvres used and their timing.

Complications and their early signs

Neonatal brachial plexus injury, presenting as an arm that is flaccid or held in an internally rotated 'waiter's tip' posture, is the complication nurses are asked about most often. Clavicular fracture can present similarly, with decreased arm movement and crepitus on palpation, and it is generally the more favourable finding since it heals without lasting deficit.

On the maternal side, watch for postpartum haemorrhage from uterine atony or vaginal and cervical lacerations, both more likely after the additional manipulation dystocia requires. Fourth-degree perineal lacerations are also more common with this delivery. Ongoing heavy bleeding, a boggy fundus, or tachycardia in the recovery period should prompt immediate reassessment.

Teaching that changes outcomes

Parents leaving with a newborn who has a visible arm injury need a clear, honest explanation of what happened and why it could not have been predicted in most cases. Explain that the manoeuvres used, McRoberts and suprapubic pressure, are the evidence-based first response and that brachial plexus injuries frequently resolve with physiotherapy over the following months.

Before discharge, teach the family how to perform passive range-of-motion exercises on the affected arm if a plexus injury is diagnosed, and confirm they have a follow-up appointment with paediatric orthopaedics or neurology arranged rather than left to be scheduled later. For the mother, review signs of delayed postpartum haemorrhage and when to seek urgent care after a complicated delivery.